NCLEX-PN

Category - Safety

A client is placed in restraints after becoming extremely aggressive during group therapy. Which of the following actions by the nurse ensures the client’s safety?
  1. The nurse uses a half-bow when securing the restraints to the side rails
  2. The nurse uses a half-bow when securing the restraint to the bed frame
  3. The circulation in the restrained extremities is checked every 2 hours
  4. The restraints are removed every 8 hours
Explanation
Answer: B - The restraints are secured to the bed frame using half-bows for quick or fast release. They are not secured to the side rails. The circulation should be checked every 30 minutes and the restraints should be removed every 2 hours.
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